CLINICAL PEARLS FOR

SUCCESS IN MEDICAL

RESPITE2018 MEDICAL RESPITE TRAINING SYMPOSIUM

PHOENIX, ARIZONAOCTOBER 1-2, 2018

PRESENTERS:

DAVE MUNSON, MD

MEDICAL DIRECTOR

BOSTON HEALTHCARE FOR THE HOMELESS

KIM DESPRES, RN DHA

RN PROGRAM DIRECTOR CIRCLE THE CITY

LEARNING OBJECTIVES

• Understand the variety of staffing models

used in medical respite

• Review admission criteria for medical

respite programs

• Discuss specific clinical scenarios and

review best practices for successful and

safe care

TYPES OF MEDICAL RESPITE

• Apartment/Motel rooms

• Homeless Shelter

• Transitional Housing

• Assisted Living/Nursing Home

• Substance Abuse treatment

• Stand-alone facility

STAFFING MODEL EXAMPLES

• Substance abuse clinic

→ On site clinic

• Nursing home/assisted living

→ Contracted services

→ Potential to utilize existing staff

• Shelter based and transitional housing

→ Contracted services

• Home care

• Providers

STAND-ALONE RESPITE

STAFFING MODEL

• Providers 7 days a week→ Two providers per day for 50 patients

→ MD on call nights and weekends

• Nurses 24/7→ Three nurses (2 LPN’s and 1 RN) daily

→ One LPN at night

• Behavioral Health→ Psychiatry: both contracted and employed

→ Substance abuse mental health counseling

STAND-ALONE RESPITE

STAFFING MODEL

• Security

• Health unit coordinators

• Case management

→Two for 50 patients

• Physical therapy

• Driver

• Respite assistants

→Two on day and one on nights

STAND-ALONE RESPITE

STAFFING MODEL

• Volunteers, Volunteers, Volunteers!!

Edgar

In memory…..Barney

MEDICAL RESPITE: ADMISSION

CRITERIA

I KNOW IT WHEN I SEE IT

MEDICAL RESPITE: ADMISSION

CRITERIA

• Clinical Considerations

• Behavioral Considerations

• Staffing/facility considerations

• Partnership considerations

ADMISSION CRITERIA: CLINICAL

CONSIDERATIONS

• Case: 55F with T2DM, CKD, opioid use disorder (OUD) referred to

medical respite from hospital after right below knee amputation.

Relevant issues in referral:

→ Newly on insulin and prescribed QID finger sticks/injections

→ On short acting pain medication but would like to start treatment

for her opioid use disorder

→ Daily wound care dressings at surgical site

→ Discharge summary requests weekly labs

→ Worked with physical therapy in hospital and struggled with

transfers. Skilled rehab was recommended but the patient could

not be placed.

ADMISSION CRITERIA: CLINICAL

CONSIDERATIONS

• Independence with ADLs

• Substance Use Disorders→ Ability to do detoxification

→ Ability to initiate buprenorphine (x-waiver required)

• Medication independence/safety

ADMISSION CRITERIA: CLINICAL

CONSIDERATIONS

• Laboratory monitoring

• Primary psychiatric patients

• Medication independence/safety

ADMISSION CRITERIA: BEHAVIORAL

CONSIDERATIONS

• Case: 34M with TBI, alcohol use disorder (AUD) and recurrent

cellulitis of his toe referred to medical respite by street

medicine team:

→ Refuses to go to ER/hospital but seems appropriate medically for respite and he wants to come in

→ There is a potential housing opportunity for him

→ He is prone to outbursts and during his last time in respite

(18 months ago) he was verbally abusive to staff resulting

in a bar

ADMISSION CRITERIA: BEHAVIORAL

CONSIDERATIONS

• Issue #1: Safety→ How to ensure that staff feel safe.

→ How to ensure that other patients feel safe

• Issue #2: Bars/Readmission Criteria→ How long of a bar is long enough

→ What is the process for mitigation

• Issue #3: Support→ Develop behavioral support plans

ADMISSION CRITERIA: FACILITY

CONSIDERATIONS

• Quick Case 1: 56M with COPD on 2L O2 is referred from hospital after a COPD exacerbation→ How will you ensure he has enough oxygen?

• Quick Case 2: 64F with morbid obesity is referred for management of RLE cellulitis→ Do you have adequate facilities (bed, toilet) to support the patient?

• Quick Case 3: 34M with TBI, PTSD admitted for diabetes management. He has an emotional support dog.→ Can you accommodate the patient and his animal

ADMISSION CRITERIA:

PARTNERSHIPS

• Tailor your services to the needs of

your partners

ADMISSION CRITERIA:

IMPLEMENTATION

• Standardized referral process

• Dedicated staff

• Eyes on the ground

ADMISSION CRITERIA: EYES ON

THE GROUND

• Dedicated Nurse - Liaison→Two days a week at major referring hospital

→Rounds on homeless inpatients

→Coordinates with inpatient teams, ER

→Close contact with our admissions office

3 CASES TO DISCUSS AND

DEVELOP

• Break into 3 groups

• For your assigned case1) Discuss any barriers

2) Explain any policies or procedures that would

need to be developed

3) Discuss any trainings that staff would need

CLINICAL SCENARIOS AND BEST

PRACTICES

• Opioid use disorder

• 52M with AIDS and OUD is referred from hospital for wound

care related to an abscess. He has pain related to his

dressing change and remains on oxycodone 10mg BID but wants to start MAT during his respite stay.

→ What processes do you need to be able to accept this

patient

→ What staff trainings and skills are required

→ Develop a protocol that would allow your program to

care for this patient

CLINICAL SCENARIOS AND BEST

PRACTICES

• Bed bug infestation

→ Cleaning staff or nursing assistants started the weekly cleaning of

the female dorm

→ While changing the sheets, they noticed black dots on the box

spring cover.

→ They weren’t quite sure what to do

What does your staff do at this point Who do they report this to?

What are next steps?

What is your policy and procedure for detecting and preventing bed bugs?

Were all steps followed?

Lessons learned?

CLINICAL SCENARIOS AND BEST

PRACTICES

• IV antibiotics

• 28F with OUD is referred from hospital to complete a 6 week

course of IV vancomycin for septic arthritis.

→ What processes do you need to be able to accept this patient

→ What staff trainings and skills are required to care for her

safely

→ How would you manage her OUD?

→ Develop a protocol that would allow your program to

care for this patient

BEST PRACTICES – OPIOID USE DISORDER

• Recognize and treat withdrawal→COWS assessment built into EMR

→Detox/induction protocol with buprenorphine

• Increase behavioral health support→Daily SUD group, individual counseling as

needed

• Support staff!!→Trauma informed care trainings

→Small group sessions to address behaviors/burn

out

BEST PRACTICES -

INFESTATION

BEST PRACTICES: IV ANTIBIOTICS

• Admission criteria→ Require central access (PICC vs midline) before admission

→ Require confirmation

→ Pharmacy

• Clinical guidelines→ Frequency of dosing

→ Administration of medication

• Teaching and training

Questions/ Discussion